Long-term use of FK 506 in living related liver transplantation

Tremor Induced by Cyclosporine, Tacrolimus, Sirolimus, or Everolimus: A Review of the Literature

Calcineurin inhibitors such as cyclosporine and tacrolimus are immunosuppressant drugs that are known to induce tremors. Non-calcineurin inhibitors such as sirolimus and everolimus have also reportedly been accompanied by tremors, albeit less likely. However, the prevalence rates reported in the literature are notably wide, and the risk profiles for these drug-induced tremors are less understood. We searched PubMed to extract data on the risk of tremors with these drugs when prescribed for various transplant and non-transplant indications. We ascertained whether the risk of drug-induced tremor is influenced by the underlying diagnosis, dosing formulations, drug concentrations, and blood monitoring. We extracted data on treatment strategies and outcomes for tremors. Articles were primarily screened based on English language publications, abstracts, and studies with n ≥ 5, which included case series, retrospective studies, case-controlled studies, and prospective studies. We found 81 eligible studies comprising 33 cyclosporine, 43 tacrolimus, 6 sirolimus, and 1 everolimus that discussed tremor as an adverse event. In the pooled analysis of studies with n > 100, the incidence of tremor was 17% with cyclosporine, 21.5% with tacrolimus, and 7.8% with sirolimus and everolimus together. Regarding the underlying diagnosis, tremor was more frequently reported in kidney transplant (cyclosporine 28%, tacrolimus 30.1%) and bone marrow transplant (cyclosporine 40%, tacrolimus 41.9%) patients compared with liver transplant (cyclosporine 9%, tacrolimus 11.5%) and nontransplant indications (cyclosporine 21.5%, tacrolimus 11.3%). Most studies did not report whether the risk of tremors correlated with drug concentrations in the blood. The prevalence of tremors when using the twice-daily formulation of tacrolimus was nearly the same as the once-daily formulation (17% vs 18%). Data on individual-level risk factors for tremors were lacking. Except for three studies that found some benefit to maintaining magnesium levels, there were minimal data on treatments and outcomes. A large body of data supports a substantive and wide prevalence of tremor resulting from tacrolimus use followed by cyclosporine, especially in patients receiving a kidney transplant. However, there is little reporting on the patient-related risk factors for tremor, risk relationship with drug concentrations, treatment strategies, and outcomes.

Tacrolimus-induced hyperpigmentation in a patch of vitiligo

A 10-year-old boy had vitiligo vulgaris involving limited areas and was prescribed topical tacrolimus ointment (0.03%), as the lesions were present in the infraorbital area in addition to other areas including the arms, thighs, and around the knees and ankles. Within 2 months of starting treatment, he had evidence of diffuse repigmentation of all the patches of vitiligo. Two months later, all the lesions repigmented completely with excellent color matching except those in the infraorbital area. The parents were anxious due to brownish hyperpigmentation in the previous patch of vitiligo in infraorbital area (Figure). He had no irritation or burning sensation in the areas of application. There was no history of photosensitivity. The patient was applying tacrolimus once at night, and no photoprotection was advised. Due to location of the lesion in the infraorbital area, a cosmetically important site, the parents did not consent for punch biopsy. The hyperpigmentation was temporary, with reappearance of depigmentation within 1 month of discontinuing topical tacrolimus application.

Mucosal Pigmentation after Oral Lichen planus Treatment with Topical Tacrolimus

Erosive oral lichen planus (OLP) is a painful chronic inflammatory disease that is sometimes resistant to systemic or topical therapies. Topical steroids remain the mainstay of therapy, but topical tacrolimus has recently been used to treat OLP resistant to topical corticosteroids. Topical tacrolimus appears as an effective and safe treatment of symptomatic OLP. We report the first histopathologically documented case of oral mucosa pigmentation after OLP treatment with topical tacrolimus. The relation between tacrolimus treatment and staining was suggested by the appearance of pigmentation during topical tacrolimus treatment and its clinical disappearance when treatment was stopped. Histopathology showed an increase in melanocyte numbers and melanogenesis.

An unusual oral chronic graft-versus-host disease-like syndrome following a liver transplant

BACKGROUND

Giving the immunosuppressive drug tacrolimus (FK506) to liver transplant patients has helped to considerably reduce oral side effects such as gingival hyperplasia. Patients taking cyclosporin who suffer from gingival hyperplasia are often switched to tacrolimus.

METHODS

We present here a pediatric liver transplantation case study. The patient has been followed for 5.5 years. She developed oral lesions that resulted in the immunosuppressive therapy being changed from tacrolimus to cyclosporin. In clinical terms, the atypical pathology consisted of hyperpigmented patches on the gingival margin, the internal surfaces of the cheeks, and the intraoral surfaces of the lips. When located on the lips, the hyperpigmented patches were associated with pruriginous and edematous lesions.

RESULTS

Optical and electronic microscopic examinations of a gingival tissue sample revealed the presence of melanin incontinence and lichenoid lesions with degenerated keratinocytes and a mild infiltrate of lymphocytes. This points to a chronic graft-versus-host disease (cGvHD)-like syndrome linked to tacrolimus. This diagnosis was given further credence by improvement in the lesions following the switch to cyclosporin.

CONCLUSION

To our knowledge, this is the first reported case of tacrolimus-associated chronic GvHD-like syndrome occurring in the oral mucosa.

Hypertension and renal dysfunction in long-term liver transplant recipients

1. A 10-year survival rate of 60% or greater after orthotopic liver transplantation (OLT) is expected. 2. Renal dysfunction is common after OLT. 3. Patients without early renal dysfunction after OLT are at low risk for long-term renal dysfunction. 4. Hypertension occurs in greater than 50% of long-term survivors. 5. Immunosuppressive protocols must be adjusted early to avoid long-term complications.